Comprehensive Prevention

Box 2: Male Circumcision for HIV Prevention

Three significant, experimental trials recently conducted in South Africa³³, Kenya³⁴ and Uganda³⁵, have led the WHO and UNAIDS to affirm the efficacy of male circumcision in reducing female-to-male transmission of HIV “beyond reasonable doubt”.³⁶ According to these experimental studies, when male circumcision is performed by well-trained medical professionals, men’s risk of acquiring HIV infection from an HIV-positive female partner is reduced by approximately 60 percent.³⁷ Based on a reduced risk of 60 percent, it has been estimated that two million new HIV infections and 300,000 deaths could be averted over the next ten years.³⁸

Recent data suggests that there are not major ethnic or cultural barriers to male circumcision in most of sub-Saharan Africa. Thirteen acceptability studies conducted in nine sub-Saharan African countries show that 29 to 81 percent of uncircumcised men wish to be circumcised, 50 to 70 percent of women wanted their partners to be circumcised, and 50 to 90 percent of parents would circumcise their sons.³⁹ Still, the expansion of male circumcision services must be considerate of ethical and legal issues, and of course respectful of men’s sexual and reproductive rights. Further research is needed to better understand perceptions of male circumcision and to develop appropriate education and counseling messages among different groups of people.⁴⁰

Ultimately, promotion of male circumcision should never serve as the sole method of prevention, but rather comprise one component of HIV prevention and reproductive health services. There is no guarantee that circumcision prevents female-to-male transmission on every occasion. Secondly, early research findings demonstrate that circumcision of HIV-positive males does not directly contribute to reducing transmission to negative female partners.⁴¹ However, it is expected that women will benefit in the long-run, particularly those living in high HIV prevalence settings with low male circumcision rates, as an overall reduction of HIV-positive men in the population occurs, and thus a reduced risk of acquiring the virus. Male circumcision will be most effective in preventing the spread of HIV when it is accompanied by HIV counseling and testing, diagnosis and treatment of STIs, condom promotion, behavioral change communication and promotion, as well as other prevention methods as they are proven effective,^{42 43} including access to male and female condoms.

 

Expanding voluntary counseling and testing services (VCT), ^{52 53 54} and treating certain STIs may contribute to HIV prevention⁵⁵. In places where HIV is transmitted among IDUs, promoting safe injection practices is critical. And of course, continued commitment is needed to developing microbicides [see Box 3: Microbicides] and an effective AIDS vaccine, which will hopefully someday spearhead comprehensive HIV prevention.

Box 3: Microbicides

There is great anticipation for the introduction of microbicides—an exciting female initiated technology that promises to broaden the scope of comprehensive HIV prevention. While scientists are currently testing products, no safe and effective microbicide is currently available to the public and experts estimate that a microbicide that is at least 33 percent effective is still five years away.⁴⁶ Given this forecast, improved programming and promotion of both male and female condoms must continue.

The term "microbicides" is broad and refers to a variety of products that, when applied topically, will be designed to prevent the sexual transmission of HIV and certain other STIs.⁴⁷ Some of these products may provide bi-directional protection, protecting women’s sexual partners by disabling HIV in both semen and vaginal secretions. Certain microbicides may also be protective for anal sex, and some products may prevent pregnancy, while others may offer women an HIV prevention option that can be used when trying to conceive. Even if not 100 percent effective, microbicides could offer valuable back-up protection to couples who use them with condoms. Microbicides may take many forms, including gels, creams, suppositories, films, sponges or rings.

The potential of microbicides to provide women with a defense against HIV that they can initiate without the consent of their partners is a crucial innovation—one that does not currently exist. In parts of the world where the status of women makes it difficult for them to refuse sex or negotiate condom use, microbicides would greatly improve the range of protective options available to women.

The total global investment in the research and development of microbicides has been steadily increasing over the past seven years, amounting to US $222 million in 2006.⁴⁸ Public agencies and institutions were the largest contributor, accounting for nearly 86 percent of this investment. This growth in funding can be attributed to increased confidence in the eventual success of these products, as well as increased awareness that there is no silver bullet to HIV prevention and expanding the range of available prevention options remains important.⁴⁹

Please see the Appendix for this section's endnotes.